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Home and Out-of-Hospital Birth in Texas

Chandler Sparks, DO, MPH, MS

Disclosures• I have no financial disclosures

• I created and maintain TexasHomeBirth.com

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Learning Objectives1. Understand the current state of Out-of-hospital birth practice and regulation in Texas

2. Be able to discuss key information about regulation, safety, and standards of care

3. Become equipped with tools to help patients navigate this challenging issue

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Your Stories

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My Story

My Story

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My Story

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The State of Out of Hospital Birth

- Growing in popularity, 1.4% of Texas births

- Unregulated in many states

- Limited oversight

- Extremely polarizing

- Limited unbiased information for patients

- US versus Europe

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PROVIDERSLegal

• Physicians

• Certified Nurse Midwives

• Licensed Midwives

– Usually Certified Professional Midwives

Not Legal

• Traditional Midwives/Parteras

• Certified Midwives

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PROVIDERS

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PROVIDERS

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http://gatehousenews.com/failuretodeliver/explore-the-database/#states

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CPM TrainingOption 1: Apprentice with a qualified midwife, completing an Entry-Level Portfolio Evaluation Process (PEP)

– observe ten births,

– assist at 20 births

– attend 20 births as primary midwife (under supervision). The teaching midwife must have three years experience as a CPM or have attended 70

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CPM TrainingOption 2: Attend a midwifery program or school

– If the school is accredited by the Midwifery Education Accreditation Council, graduation qualifies a midwife for the NARM written exam

– If the school or program is not MEAC accredited, the applicant must complete the Entry-Level Portfolio Evaluation Process

– Texas Schools

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CPM TrainingOption 3: Obtain a license from their state first, and then apply for certification from NARM.

- applies if the aspiring midwife's licensing state has met "educational equivalency" requirements set by NARM.

- must also report ten births as primary midwife in the last three years. They are then awarded the CPM credential.

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Global Standards

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Global Standards

Two-thirds of American CPMs are trained in self-study and apprenticeship programs or are certified after state licensure, and do not meet ICM global standards for midwifery education and training

ACOG Policy Statement

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EVIDENCE• Quality of studies

• MANA Stats 2004 - 2009

• Grunebaum, et al 2009

• GateHouse Media – Failure to Deliver

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21 https://onlinelibrary.wiley.com/doi/pdf/10.1111/jmwh.12172

EVIDENCE• Home vs Hospital: for mothers

– Increase maternal satisfaction

– Decreased medical interventions

– Decreased cesarean rate

– Increased likelihood of unmedicated birth

– Increased risk of postpartum hemorrhage

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RATES COMPAREDMANA Stats

2.06/1000

Breech

22.5/1000

TOLAC

4.75/1000

PPH

15.5%

CDC Wonder

0.7/1000 mortality

1.8/1000

0.7/1000

3.3%

23Journal of Midwifery and Womens Health

EVIDENCE• Home vs Hospital: for babies in FTD analysis

– Increased risk of seizures

– Increased risk of HIE

– Tripled mortality rate overall

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NEONATAL MORTALITY

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REGULATION• Licensure versus Certification

• TDLR - Texas Midwives Advisory Board

• NARM

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Texas Licensure• Application

• NARM exam

• Satisfactory education course (PEP accepted)

• Current certification in CPR for professionals and NRP

• Newborn Screening collection training

• Pay a fee

• Pass TDLR jurisprudence exam

• Criminal background check

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BIRTHING CENTERS• Regulated by the Health Facility Compliance Group

https://www.dshs.texas.gov/facilities/compliance-contact.aspx

• 77 centers in Texas

http://gatehousenews.com/failuretodeliver/explore-the-database/#birthcenters

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When Things Go WrongHospital

• Peer Review

• Medical/Nursing Board

• Malpractice Insurance

Home Birth

• File complaint to TDLR

• Voluntary peer review if maintaining credential

• Malpractice Insurance??

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Penalties

• Practicing medicine without a license is a felony

• Practicing nursing without a license is a felony

• Practicing midwifery without a license currently carries no civil or criminal penalty as of September 2017.

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When Things Go Wrong

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STANDARDS OF CARE• Exist in every area of medicine and nursing

• 200 ACOG Practice Bulletins, 30+ from ACNM

NARM Statement“...each midwife is an individual with specific practice protocols that reflect her own style and philosophy, level of experience, and legal status, and that practice guidelines may vary with each midwife. NARM does not set protocols for all CPMs to follow, but requires that they develop their own practice guidelines in written form”.

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PRENATAL CAREAssess for and refer to physician or delegate of physician for:

• infection requiring abx

• Hepatitis

• non-insulin dependent DM

• thyroid disease

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• current drug or alcohol abuse• asthma, • abnormal pap smear during the

current pregnancy• seizure disorder• prior cesarean (classical or

vertical incision requires transfer of care

• Multiple gestation

REFERRAL CONTINUED• - Hx miscarriage, neonatal death, any congenital malformation

or genetic disorder

• - significant vaginal bleeding

- maternal age less than 15 at EDC

- cancer or hx cancer

- psychiatric illness

- any other condition or symptom which could adversely affect the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge

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PRENATAL CARE - TRANSFER• placenta previa in the third trimester;

• Human Immunodeficiency Virus (HIV) positive or Acquired Immunodeficiency Syndrome (AIDS);

• cardio vascular disease, including hypertension, with the exception of varicosities;

• severe psychiatric illness;

• history of cervical incompetence with surgical therapy;

• pre-term labor (less than 37 weeks);

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TRANSFER CONTINUED• previous uterine surgery involving incision into the uterine

myometrium, other than a low transverse cesarean section

• preeclampsia/eclampsia;

• documented oligo-hydramnios or poly-hydramnios;

• any known fetal malformation;

• Preterm Premature Rupture Of Membranes (PPROM);

• intrauterine growth restriction

• insulin dependent diabetes;

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TRANSFER CONTINUED• triplet or higher order multiple gestation;

• Rh or other blood group isoimmunization;

• active cancer history or history of ovarian, breast, uterine, or cervical cancer;

• undiagnosed vaginal bleeding lasting longer than two weeks, or;

• any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge

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TRANSFER CONTINUED• If a client has reached 42.0 weeks gestation and is not yet in

labor, the midwife must immediately either:

• collaborate with a physician and obtain appropriate antenatal testing, in order to continue midwifery care; or

• initiate transfer and document that action in the midwifery record.

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TRANSFERSDuring Labor, Emergency transfer if…

• prolapsed cord;

• chorio-amnionitis (infection inside the uterus of the placenta or amniotic fluid);

• uncontrolled hemorrhage;

• gestational hypertension/preeclampsia/eclampsia;

• severe abdominal pain inconsistent with normal labor;

• a non-reassuring fetal heart rate pattern;

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TRANSFERS CONTINUED• thick meconium unless the birth is imminent;

• visible genital lesions suspicious of herpes virus infection;

• evidence of maternal shock;

• preterm labor (less than 37 weeks);

• presentation(s) not compatible with spontaneous vaginal delivery;

• laceration(s) requiring repair beyond the scope of practice of the midwife;

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TRANSFERS CONTINUED• Seizure;

• failure to progress in labor;

• retained placenta; or

• any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge

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WHAT IS A TRANSFER?• Transport to hospital by personal vehicle

• Call 911, provide care until they arrive

• Update the receiving clinician/hospital regarding case

• Statutes list a number of conditions for both mother and baby

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TRANSFER ISSUES• Fear

• Animosity

• Poor handoff

• Continuity

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TRANSFER GUIDELINES• Home Birth Summit – Best Practiceshttp://www.homebirthsummit.org/wp-content/uploads/2014/03/HomeBirthSummit_BestPracticeTransferGuidelines.pdf

- Collaboration, not hostility

- Standard SBAR, forms online

- Continuity preserves

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Safe Home Birth in Texas- Advocacy

- Education and Training

- Strict regulation

- Statewide data capture for analysis

- Standards of Care

- Malpractice insurance

- Niche for Family Docs

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Objectives for THB.comCreate an evidence-based web resource that

- Adequately explains the risks, standards, and regulation of the practice in Texas

- Understandable and palatable for patients in the “natural birth” community

- Is informative for clinicians

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What should you do?• Make sure parents understand risks

• Recommend appropriate resources [www.TexasHomeBirth.com]

• Know who’s who in your community

• Advocate for changes to make OOH birth safer

• Support a culture of safety and smooth transfer

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All sources available at www.texashomebirth.com